This document discusses cervical cancer prevention through a "see and treat" approach using visual inspection with acetic acid (VIA) screening in low-resource areas. It provides background on cervical cancer epidemiology in India, the rationale for screening, and details on performing VIA screening. A large cluster randomized controlled trial in Mumbai, India found that four rounds of VIA screening conducted by primary health workers reduced cervical cancer mortality by 31% compared to a control group that received only cancer education. The results demonstrate that VIA screening by primary health workers can effectively reduce cervical cancer deaths in low-resource settings.
Asccp management guidelines august 2014 ppt. Dr. Sharda Jain /Dr Jyoti Agarw...Lifecare Centre
Updated Consensus
American society of Colpscopy & cervical pathology
Guidelines 2014for Managing forAbnormal Cervical Cancer Screening Test and Cancer Precursors
Dr. Sharda Jain /Dr Jyoti Agarwal / dr. Jyoti Bhasker
Adnexal masses are commonly identified in pregnancy but they are rarely malignant. Most adnexal masses either resolve spontaneously or can be managed conservatively during pregnancy. Pregnancy may alter the serum levels of tumour markers, making the interpretation of results difficult.
Asccp management guidelines august 2014 ppt. Dr. Sharda Jain /Dr Jyoti Agarw...Lifecare Centre
Updated Consensus
American society of Colpscopy & cervical pathology
Guidelines 2014for Managing forAbnormal Cervical Cancer Screening Test and Cancer Precursors
Dr. Sharda Jain /Dr Jyoti Agarwal / dr. Jyoti Bhasker
Adnexal masses are commonly identified in pregnancy but they are rarely malignant. Most adnexal masses either resolve spontaneously or can be managed conservatively during pregnancy. Pregnancy may alter the serum levels of tumour markers, making the interpretation of results difficult.
Management of Early Stage Carcinoma CervixSubhash Thakur
This presentation covers the management of early stage carcinoma cervix (FIGO stage I to IIA). A brief introuduction to different surgical procedures and the radiation treatment techninques have been described.
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Join Dr. Alex Buckley, Assistant Professor, Division of Gynecologic Oncology at Columbia University Irving Medical Center, as he provides a comprehensive update from the Society of Gynecologic Oncology (SGO) Annual Meeting on Women’s Cancer. Dr. Buckley will break down the research presented at the conference, discuss new developments, and address your questions.
Cervical cancer global burden and where do we stand todayNiranjan Chavan
Cervical cancer is the 4th most common cancer in women worldwide but most common cause of cancer related death in India.
All over the world, including India, there is decreasing trend of cervical cancer.
Report Back from SGO 2023: What’s New in Cervical Cancer?bkling
Curious about what’s new in cervical cancer research? Join Dr. Evelyn Cantillo, gynecologic oncologist at Weill Cornell Medicine, as she shares the latest updates from the Society of Gynecologic Oncology (SGO) 2023 Annual Meeting on Women’s Cancer. Dr. Cantillo will also highlight what the research presented at the conference means for you and answer your questions about the new developments.
Fertility preservation in Cancer patientsArunSharma10
The need for fertility preservation
Chemotherapeutic drugs according to gonadotoxicity level
Fertility preservation: subject of continuous review by experts
Non-oncological conditions requiring fertility preservation
Delayed childbearing
AVAILABLE PROCEDURES FOR FP
Embryo and oocyte cryopreservation
Management of Early Stage Carcinoma CervixSubhash Thakur
This presentation covers the management of early stage carcinoma cervix (FIGO stage I to IIA). A brief introuduction to different surgical procedures and the radiation treatment techninques have been described.
Report Back from SGO 2023: What’s New in Uterine Cancer?bkling
Join Dr. Alex Buckley, Assistant Professor, Division of Gynecologic Oncology at Columbia University Irving Medical Center, as he provides a comprehensive update from the Society of Gynecologic Oncology (SGO) Annual Meeting on Women’s Cancer. Dr. Buckley will break down the research presented at the conference, discuss new developments, and address your questions.
Cervical cancer global burden and where do we stand todayNiranjan Chavan
Cervical cancer is the 4th most common cancer in women worldwide but most common cause of cancer related death in India.
All over the world, including India, there is decreasing trend of cervical cancer.
Report Back from SGO 2023: What’s New in Cervical Cancer?bkling
Curious about what’s new in cervical cancer research? Join Dr. Evelyn Cantillo, gynecologic oncologist at Weill Cornell Medicine, as she shares the latest updates from the Society of Gynecologic Oncology (SGO) 2023 Annual Meeting on Women’s Cancer. Dr. Cantillo will also highlight what the research presented at the conference means for you and answer your questions about the new developments.
Fertility preservation in Cancer patientsArunSharma10
The need for fertility preservation
Chemotherapeutic drugs according to gonadotoxicity level
Fertility preservation: subject of continuous review by experts
Non-oncological conditions requiring fertility preservation
Delayed childbearing
AVAILABLE PROCEDURES FOR FP
Embryo and oocyte cryopreservation
VIA is an attractive alternative to cytology-based cervix uteri screening in low-resource settings. Cryotherapy is the treatment option for test-positive individuals. Hereby a “Screen and Treat” approach can be integrated into existing reproductive health services in low-resource countries.
The Accuracy of Diagnostic Colposcopy using IFCPC 2011 TerminologySujoy Dasgupta
This paper was presented in the Annual Conference of Bengal Obstetric and Gynaecological Society (BOGSCON) 2014 held at ITC Sonar, Kolkata- January, 2014
Given the availability of a colposcope and a trained colposcopist this method is an essential tool for effective secondary prevention of female reproductive organ diseases. Colposcopic guided procedures enable a preceise diagnostic and consequent treatments with eventually organ preserving means. This power point presentation highlights the range of opportunities offered by Colposcopy.
Nulife module 6 screening for malignancies editedManinder Ahuja
These six modules from 2-7 are on mid life health care of women and were made with intention of training general gynecologist and other speciality into care of mid life women and have Mid Life OPD cards as mainstay of care.
Cervical cancer by dr alka mukherjee dr apurva mukherjee nagpur m.s.alka mukherjee
Cervical cancer develops in a woman's cervix (the entrance to the uterus from the vagina).
Almost all cervical cancer cases (99%) are linked to infection with high-risk human papillomaviruses (HPV), an extremely common virus transmitted through sexual contact.
Although most infections with HPV resolve spontaneously and cause no symptoms, persistent infection can cause cervical cancer in women.
Cervical cancer is the fourth most common cancer in women. In 2018, an estimated 570 000 women were diagnosed with cervical cancer worldwide and about 311 000 women died from the disease.
Effective primary (HPV vaccination) and secondary prevention approaches (screening for, and treating precancerous lesions) will prevent most cervical cancer cases.
When diagnosed, cervical cancer is one of the most successfully treatable forms of cancer, as long as it is detected early and managed effectively. Cancers diagnosed in late stages can also be controlled with appropriate treatment and palliative care.
With a comprehensive approach to prevent, screen and treat, cervical cancer can be eliminated as a public health problem within a generation.
The Newer Concepts In Endometriosis Management : Dr Sharda JainLifecare Centre
The Newer Concepts In
Endometriosis Management
ENDOMETRIOSIS IS ENIGMA
DIAGNOSTIC DELEMMA
DEBILITATING DISEASE QOL
PROGRESSIVE DISEASE
RECURRENCE IS BIG PROBLEM
NO FINAL VERDICT ON CAUSE
NO PERMANENT CURE
The exact prevalence of endometriosis is unknown, but estimates 10% in the general female population in India but up to 50% in infertile women
The Newer Concepts forReduced Surgery to preserve fertility in Endometrios...Lifecare Centre
The Newer Concepts forReduced Surgery to preserve fertility in Endometriosis
ENDOMETRIOSIS IS ENIGMA
DIAGNOSTIC DILEMMA
DEBILITATING DISEASE QOL
PROGRESSIVE DISEASE
RECURRENCE IS BIG PROBLEM
NO FINAL VERDICT ON CAUSE
NO PERMANENT CURE
The exact prevalence of endometriosis is unknown, but estimates 10% in the general female population in India but up to 50% in infertile women
Anemia Free India Gynaecologist to focuss on *12gm Haemoglobin at Delivery I...Lifecare Centre
Important Highlights
Prophylactic Iron and Folic Acid Supplementation in all six target age groups.
Intensified year-round Behaviour Change Communication (BCC) Campaign for:(a) improving compliance to IFA and deworming, (b) enhancing appropriate infant and young child feeding practices, (c) encouraging increase in intake of iron-rich food through diet and/or fortified foods (d) ensuring delayed cord clamping .
Testing and treatment of anaemia, using digital methods and point of care treatment, with special focus on pregnant women and school-going adolescents.
Addressing non-nutritional causes of anaemia
in endemic pockets with special focus on malaria, hemoglobinopathies and fluorosis
Strategies for Improving Success Rates in ART PARTLifecare Centre
Strategies for Improving Success Rates in ART
Part - 2
Strategies for Improving Success Rates in ART
Tailoring Controlled Ovarian Stimulation
Strategies for Luteal Phase in ART cycles
Endometrial Receptivity Array
How to optimize success rates in ART? : Dr Sharda JainLifecare Centre
How to optimize success rates in ART? : Dr Sharda Jain
How to improve success rates in ART?
The big debate कार्य में आनंद
Evolution of In-vitro Fertilization (IVF)
Factors Influencing IVF Success Ist Part
Strategies for Improving Success Rates in ART Second Part
Innovations & Breakthroughs in IVF Part Three
OPEN DEBATE
SOCIALEGG FREEZING : Dr Poorva Bhargav and Dr Sharda JainLifecare Centre
SOCIALEGG FREEZING : Dr Poorva Bhargav and Dr Sharda Jain
Introduction
Social egg freezing (oocyte cryopreservation for non-medical reasons) has evolved as a proactive option for women looking to extend their reproductive possibilities past their peak childbearing years
It is the process of saving or protecting eggs, or reproductive tissues so that a person can use them to have biological children in future
5. Every 7Minutes,
1 Indian woman dies of Cervical Cancer
Disease Burden
Infact India is a Capital for Cervical Cancer
6. High Economic Burden
Due to the high number of cervical cancer
cases in the population, it has the highest
total cost of secondary care (100,000 INR
per 100,000 population) relative to all other
cancers.
“Report of the National Commission on Macroeconomics
and Health”, NCMH, Ministry of H &FW, Government of India, August 2005.
7. Screening- Why?
• In many developed countries, a significant decline
in the incidence of and mortality caused by cervical
cancer has been observed in the past 30 years as a
result of screening by cytology.
• Cervical cancer has precursor, low and high grade
intraepithelial lesion, which has effective treatments
available.
• Screening also gives an opportunity for educating
women who are constantly at high risk.
8. System Failures Leading to
Cervical Cancer Diagnosis
Women do not
come in for
screening
Health care providers
do not screen women
at visits
Colposcopy for
abnormal screen
not done
Patient does not get
appropriate therapy
Patient gets cervical
cancer
Courtesy of Connie Trimble, MD, Johns Hopkins University School of Medicine, Baltimore, MD
9. Cancer Cervix –
a Global Paradox
• Cancer cervix –100% Preventable disease
WHO
• Cancer cervix –Death by incompetence
Lancet
• Cancer cervix – the unmet challange
12. Natural History of Cervical Cancer
HPV
infection
CIN 1
CIN 2,3
HPV
disappearance
Invasive CA
Avg. 10-13 yrs
Avg. 6-
24 mo
Avg. 6-
12 mo.
13. AGE SCREENING
< 21 No Screening
21-29 Cytology alone every 3 years
30-65 Acceptable: Cytology alone every 3 years*
Preferred ??: Cytology + HPV every 5 years* OR
> 65 No screening, following 3 consequetive neg prior
screens in last decade
After total hysterectomy No screening, if no history of CIN2+ in the past 20
years of cervical cancer ever
HIV-positive
-Immunosuppressed (e.g., Annually
2013 Guidelines
for prevention of Cervical cancer
• 1st
time that all 3 organizations involved with cervical cancer prevention and the
USPSTF have endorsed equivalent guidelines
14. Type of screening
• Conventional cytology
• Liquid-based monolayer cytology
• Human papillomavirus testing
• Testing in resource-poor areas
16. • Pap smears require skilled practitioners and
good laboratories to be effective,
• Most studies have found that VIA, and its
cousin VILI -- visual inspection with Lugol's
iodine -- are somewhat less specific than Pap
smears, but more sensitive
17. Overall, VIA seems to be an excellent
cervical cancer screening method for
use in low-resource settings where
Pap smears and HPV tests are
inappropriate due to either lack of
expertise or high per-test cost.
18. The general consensus is that
VIA is just as useful as the Pap
smear; it's just a matter of
determining which one is more
appropriate in any given
circumstance based on
availability of funds & trained
personnel for screening and
follow up
19. VIA generally detects more early
lesions but is associated with more
false positives.
This could conceivably lead to over
treatment, but in low-resource areas
where large numbers of women are
still dying of cervical cancer, some
governments have decided it is a
worthwhile trade-off. (African Countries)
20. in India ICPO( institute of cytology
and preventive oncology) took
initiative in developing simple
strategies like VIA in1980’s ,which
subsequently supported by other
international agencies like
IARC,LYON,FRANCE,JHPIEGO,a
nd PATH in USA etc.
23. Screening women at rural & slums
settings and following them is tedious
task for Gynaecologists
But
Motivating them once,examining and
treating them simultaneously if any
abnormality noted, can be easier
task to prevent cervical cancer!
Logic Behind See & Treat Approach
25. Accesibility of CERVIX……..
• seen instantly after putting speculum inside the vagina
and becomes apparent.
• The success of VIA lies in visualising the cervix in the
region of transformation zone in its entirely.
26. TZ lies between the original squamo-columner junction
and the new (or the present ) squamo-columner junction.
This is a highly active zone of metaplastic tissues in
which the single layered columnar epithelium is transformed
by metaplastic cellular divisions into multilayered squamous
epithelium.
27. metaplasia and what triggers it
• Exposure of columnar epithelium during ectropion to
acidic environment of vagina leads to metaplasia.(healing
process of damaged columnar epithelium)
• Region that has undergone metaplasia is transformation
zone, bound distally by SCJ E and proximally by SCJ M,
is region of mitosis as cells are
rapidly dividing during metaplasia.
The mitotic rate is higher near SCJ M That's why it
appears white with acetic acid
33. VIA
• Naked eye visual inspection of
cervix, after application of 3-5%
acetic acid to detect pre cancer
lesions is VIA
VIAC
• Magnifying cervix with an ordinary
lens is VIAC i.e visual inspection with
acetic acid aided by cervicography
34. VIAM
• Technique: is same as that of VIA but
viewning of cervix is done with magnifying
glasses of 4 mm
• Studies from South Africa and Kolkatta, India
have reported no benefit of VIAM over VIA
• Study from TMH also concluded same.
35. All of us can do it and
also can train our staff to
screen large number of
women with very little
cost
VIA
39. STEPS FOR PERFORMING VIA
• Normal Inspection after cleaning with
normal saline
• Inspection after application of acetic acid
• Inspection after application of lugols Iodine
• Examination of Vagina
41. ACETIC ACID TEST
• Coagulation of cell protein seen an interval of 1 mint.
• If white layer is very thick (opaque) that area becomes
area of concern.
• The impact of acetic acid fades away normally in 1-3 mints,
So repeated application is recommended for proper
visualization of pathological lesions.
42. Aceto white lesion
• Intensity
• Duration of stay
• speed of Appearance
• speed of disappearance
• margins Relation to SCJ
Inside TZ/ outside TZ
43. Grading of VIA Findings….
• Grade I: Flat acetowhite epithelium, snow white,
regular pattern
• Grade II: Flat but whiter acetowhite epithelium, gray
white,
• Grade-III dull oyster white,
44. Pre cancer lesions of cervix on VIA
Appearance
white translucent
ivory white
egg white with thick areas
remains for longer time
Margins
sharp and distinct
internal margins
Surface contour
Flat or raised
Abnormal vascular patterns
punctations
Wide inter capillary distance
Extent
Confined to TZ
Disappearing into
cervical canal
% of TZ involved
Satellite lesion
45. VIA and cervical cancer
screening
• 4% acetic acid is applied to cervix with the help of a cotton
pad after removing excess mucus.
• VIA recording 1 minute after application of acid.
• Positive result: acetowhite areas in the squamocolumnar
junction, or entire cervix or a growth over cervix
• WHITE PATCHES” appears due
to coagulation of cellular proteins and
indicate the abnormal epithelium.
46. VIA and cervical cancer
• What does positive VIA mean:
• Infection
• Dysplasia
• Intraepithelial lesion
• Cancer
• So, final conclusion is done by colposcopy
and biopsy which is the gold standard.
47. Effect of visual inspection with acetic acid (VIA)
screening by primary health workers on cervical
cancer mortality: A cluster randomized controlled
trial in Mumbai, India. 2013 ASCO Annual Meeting
Surendra Srinivas Shastri, Indraneel Mittra, Gauravi
Mishra, Subhadra Gupta, Rajesh Dikshit, Rajendra A.
Badwe; Tata Memorial Centre, Mumbai, India
Plenary Session, Plenary Session Including FDA Commissioner Address,
Public Service Award, and Science of Oncology Award and Lecture
48. • Cluster-randomized controlled trial in 1998 to investigate the efficacy of
VIA screening by primary health workers (PHWs) in reducing cervical
cancer mortality.
• Women aged 35-64 years with no prior history of cancer were included
• 20 clusters with an average of 7,500 eligible women per cluster.
• Four rounds of cancer education and VIA screening were conducted by
PHWs in the screening group, while cancer education was offered
once at recruitment to the control group
• Recruitment was completed in March 31, 2002. Analysed the results
at 12 years
• Recruited 75,360 women from 10 clusters in the
screening group and 76,178 women from 10
comparable clusters in the control group
49. Results
• The analysis is on an intention-to-treat basis.
• In the screening group, achieved 89% participation for screening and
79% compliance for post-screening diagnostic confirmation.
• The quality of screening by PHWs was comparable to that of an expert
gynecologist (κ=0.84).
• The incidence of invasive cervical cancer was 26.74 per 100,000 in the
screening group and 27.49 per 100,000 in the control group.
•
• The screening group showed a 31% reduction in cervical cancer
mortality (p=0.003) compared to the control group.
• A 7% reduction was also observed in all-cause mortality .
50. Conclusions
• VIA screening conducted by PHWs
significantly reduced cervical cancer
mortality.
• VIA screening is easily implementable
and could prevent 22,000 cervical cancer
deaths in India.
51. VILI
• Technique is same as that of VIA but instead of acetic acid, lugol’s
iodine is applied to cervix and end result is change in color to yellow
over positive areas.
• Sankaranarayanan et al did a multicenter study in South Africa and
India on VILI and screening of cervical cancer.
• Sensitivity of VILI turned out to be 86.7-90%.
• Authors gave the reason of such high sensitivity of VILI: the
yellow color changes associated with a positive VILI test result
are more easily recognized by the health workers compared with
the acetowhite changes associated with VIA.
Best Pract Res Clin Obstet Gynaecol. 2012
56. Cryotherapy
• Cryotherapy destroys abnormal
tissue on the cervix by freezing it by
cold coagulation using ice cold gas .
• gases can destroy cells upto 3 mm
by co2 and 5 mm by nitrous oxide.
57. advantages
• Safe
• One visit treatment
• OPD procedure
• No anaesthesia
• No adverse effects on reproduction
58. LEEP
• Large loop electrical procedure
Criteria for LEEP
AWL covering > 75% of TZ
Lesion with abnormal blood vessels
Persistent lesion after cryo
Disparity between cytology, VIAC and
histology
Limits of lesion not visible.
59. To conclude
•Cervical cancer is a preventable cancer .
•We as gynecologists can do a lot to make
an impact to decrease this disease burden.
•See and treat can be a successful mantra
in our country if all gynecologists come
forward to give their due contribution to this
country where they have been trained.
Now this is our turn to give back
Editor's Notes
He first reported that uterine cancer could be diagnosed by means of a vaginal smear in 1928, but the importance of his work was not recognized until the publication, together with Herbert Traut, of Diagnosis of Uterine Cancer by the Vaginal Smear in 1943. The book discusses the preparation of vaginal and cervical smears, physiologic cytologic changes during the menstrual cycle , the effects of various pathological conditions, and the changes seen in the presence of cancer of the cervix and of the endometrium of the uterus . He thus became known for his invention of the Papanicolaou test, commonly known as the Pap smear or Pap test , which is used worldwide for the detection and prevention of cervical cancer and other cytologic diseases of the female reproductive system. In 1961 he moved to Miami, Florida, to develop the Papanicolaou Cancer Research Institute at the University of Miami, but died in 1962 prior to its opening. Papanicolaou was the recipient of the Albert Lasker Award for Clinical Medical Research in 1950. [3] Papanikolaou's portrait appeared on the obverse of the Greek 10,000-drachma banknote of 1995-2001, [4] prior to its replacement by the Euro. In 1978 his work was honored by the U.S. Postal Service with a 13-cent stamp for early cancer detection.